
{% extends "home/base.html" %}

<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>Welcome to xxx hospital</title>
</head>
<body>
{% block title %}Register{% endblock %}
{% block heading %}Register Patient{% endblock %}

{% block body %}
<div class="row">
  <form class="col s12" action='/loginmodule/pa_register/' method='POST'>
    {% csrf_token %}
    <div class="row">
      <div class="input-field col s6">
        <input type="text" name="first_name" id="first_name" class="validate" required>
        <label for="first_name" >First Name</label>
      </div>
      <div class="input-field col s6">
        <input type="text" name="last_name" id="last_name" class="validate" required>
        <label for="last_name" >Last Name</label>
      </div>
      <div class="input-field col s6">
        <input type="text" name="username" id="username" class="validate" required>
        <label for="username" >Username</label>
      </div>
      <div class="input-field col s6">
        <input type="text" name="contact_no" id="contact_no" class="validate" maxlength="11" required>
        <label for="contact_no" >Contact Number</label>
      </div>
      <div class="input-field col s6">
        <input type="password" name="password1" id="password1" class="validate" required>
        <label for="password1" >Password</label>
      </div>
      <div class="input-field col s6">
        <input type="password" name="password2" id="password2" class="validate" required>
        <label for="password2" >Confirm Password</label>
      </div>
      <div class="input-field col s6">
        <input type="email" name="email" id="email" class="validate" required>
        <label for="email" >Email</label>
      </div>
      <div class="input-field col s6">
        <input type="text" name="identity" id="identity" class="validate" required>
        <label for="identity" >ID_number</label>
      </div>

      <div class="input-field col s12">
        <textarea name="address" id="address" class="materialize-textarea" required></textarea>
        <label for="address" >Address</label>
      </div>
      <div class="input-field col s6">
        <input type="date" name="dob" id="dob" required>
        <label for="dob" class="active">Birthdate</label>
      </div>
      <div class="input-field col s6">
        <select name="blood_group" id="blood_group" class="validate" required>
          <option value='O-'>O-</option>
          <option value='O+'>O+</option>
          <option value='A-'>A-</option>
          <option value='A+'>A+</option>
          <option value='B-'>B-</option>
          <option value='B+'>B+</option>
          <option value='AB-'>AB-</option>
          <option value='AB+'>AB+</option>
        </select>
        <label for="blood_group" >Blood Group</label>
      </div>

      <button type="submit" class="btn" >Register</button>
    </div>
  </form>
</div>
{% endblock %}

</body>
</html>